Here is my talk from Therapyexpo. if you are wondering what the Egyptian theme is all about slide two outlines the first known clinical test for the lumbar spine from a text written ~3000 years ago

1. Clinical Tests for the
Lumbar Spine
John Doyle
Physiotherapy Learning & Development Manager, Nuffield Health
Extended Scope Physiotherapist, Frimley Health NHS Trust
@JPTDoyle

2. Thou shouldst say to [the
patient]: ‘Extend now thy
two legs and contract both
again.’ When he extends
them he contracts them
both immediately because
of the pain he causes in the
vertebra of his spinal
column in which he suffers
van Middendorp (2010) Eur Spine J

3. One who has a
wrenching strain in the
vertebral column of his
lower back, this is a
medical condition I can
treat van Middendorp (2010) Eur Spine J

4. Are we any better than the
ancient Egyptians at
figuring out back pain?

5. We definitely know more than the Ancient
Egyptians about …
Pathology
Epidemiology
Pain
Diagnostic Imaging
Statistics

6. And we definitely have more clinical tests…

7. 162% increase in prevalence
between 1992 and 2006

8. Days of sick certification
0
1000
2000
1950 1960 1970 1980
Male
Female
Waddell 1987

9. Back pain has always existed
Disability has not!

10. For most serious pathology clinical tests
are of questionable value
Subjective questions are more valuable for screening
Neurological examination
Baseline assessment
Onward referral
Fairbank et al (2011) Evid Based Spine Care J
Henscke et al (2013) Cochrane Database of Systematic Reviews

11. Spinal Stenosis

13. Study performed in tertiary
referral centre
Patients quite likely to have
spinal stenosis

14. Index of suspicion
Abnormal
Neurological
Examination
Abnormal
Romberg
Test
Treadmill
Test
Wide Based
Gait

15. Index of suspicion
Sign +ve LR -ve LR
Absent Achilles Reflex 2.8 0.58
Decreased Pin Prick Sensation 2.5 0.90
Decreased Vibration Sense 2.1 0.69
Muscle Weakness 2.1 0.68
Abnormal Romberg Test 4.3 0.67
Earlier Onset Of Symptoms: Flat
Treadmill
4.0 0.39
Longer Total Walking Time: Inclined
Treadmill
6.3 0.54
Wide Based Gait 14 0.59
De Schepper et al (2013) Spine

16. Lumbar Disc
Herniation &
Radiculopathy

17. Index of suspicion
Pain on
Palpation
Abnormal
Neurological
Examination
Straight Leg
Raise
Crossed
Straight Leg
Raise

18. Index of suspicion
Sign Sensitivity Specificity
Bell Test (palpation) 0.49 0.63
Straight Leg Raise 0.92 0.28
Crossed Straight Leg Raise 0.28 0.90
Van der Windt et al. Cochrane Database of Systematic Reviews 2010

20. Possibly the SIJ
Maybe the disc
Probably not the facet joints

21. Compression
Sacral Thrust
Gaenslen
Thigh ThrustDistraction
Laslett et al 2005 Manual Therapy

22. Index of suspicion
Sign +ve LR -ve LR
One positive test 1.78 0.00
Two positive tests 2.73 0.10
Three positive tests 4.29 0.80
Four positive tests 3.20 0.49
Five positive tests 2.13 0.84
Laslett et al 2005 Manual Therapy

23. Sensitivity Specificity
0.38 0.89
Centralisation of symptoms
on repeated movements in
the diagnosis of disc pain
But…..
What if there are no
peripheral symptoms???
Hancock et al 2007 Eur Spine J

24. Can you differentiate between disc/ facet joint
pain? Does it matter?So What?!?!
Not just pathoanatomical focus
Pain mechanisms approach
Understand all contributing factors

26. ‘Don’t have any faith
really, what I want to find
out is what is causing
the pain all through my
body and I
seem to meet a blank
wall’
‘My back was hurting. I
tell the doctor what’s up.
And he still won’t
examine me to see if I’m
telling the truth or not
you can’t fix a car just by
looking at it’
‘Being
believed is the
most
Important’

27. Palpation
Neurological
Assessment
Range of Motion
Testing
Functional
Demo
Muscle Testing

28. Strength and endurance
deficits exist in some
patients with low back
pain
? Relevance of test
position and contraction
type?
Simple baseline of
patients exercise
capacity?

29. Patients able to perform at
least a 60 second hold on
Biering-Sorensen
endurance test

30. Is the best ‘clinical test’ done
with a pen?

31. Pain Function Distress
Return To
Work
Fear
Avoidance

32. I’m a Mckenzoid
Combined
Movement Theory
For All!!!
We Want Cognitive
Functional Therapy!!

34. Are we any better than the
ancient Egyptians at
figuring out back pain?
Yes! But only if
we take a wider
thinking approach
to the patient

35. Can you differentiate between disc/ facet joint
pain? Does it matter?
To be better than the ancient Egyptians
Think pain mechanisms not just tissues
Understand the contributing factors
Try to understand the value of tests
Use a variety of relevent tests to
understand your patients function &
disability

36. One who has a
wrenching strain in the
vertebral column of his
lower back, this is a
medical condition I can
treat
Treatment:
You must lay him stretched
out/prostrate and prepare for him...
van Middendorp (2010) Eur Spine J

37. Can you differentiate between disc/ facet joint
pain? Does it matter?Thanks!
#Therapyexpo
@JPTDoyle